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Full text of "Diseases Of The Nose Throat And Ear"

CHAPTER 61
CHRONIC MASTODDITIS

Acute infections of the middle ear in the acellular type of mastoid process
may resolve if the virulence is slight and drainage is free. In more severe
infections the bony walls are involved with the formation of granulation
tissue resulting in chronic suppuration. Spread of infection may also occur
to the labyrinth or intracranially either at the time of the original infection
or later. Most cases of chronic mastoiditis, however, arise as a complication
of chronic suppurative otitis media of attico-antral type and may therefore
be further complicated by the presence of cholesteatoma.

SYMPTOMS. Except in cases of acute exacerbation of infection pain is not
a usual symptom but when present it is generally due to retention of discharge
and this is regarded as a danger signal. Discharge is usually foul-smelling,
abundant and creamy and persistent despite conservative treatment. The
presence of granulation tissue which rapidly recurs after removal is very
suggestive of bone infection and gentle probing may reveal the roughness
of carious bone. Deafness of a conductive type is present, its severity depend-
ing upon the integrity or otherwise of the ossicular chain. A hearing loss
exceeding 50 dB is regarded as indicative of interruption of the ossicular
chain, found most often at the incudo-stapedial joint. Sometimes hearing
loss is diminished by the continuity being maintained by part of a mass of
cholesteatoma. Bulging of the meatal wall may occur from erosion of the
bony wall by cholesteatoma and a discharging sinus may develop at this
site. Facial paralysis may develop during the course of the disease.

TREATMENT. In cases of tubotympanic disease with an odourless muco-
purulent discharge from an anterior or central perforation of the drumhead
bone destruction is not a causative factor of persistent discharge. In these
cases medical treatment should be continued in preference to mastoid
surgery. Where the symptomatology points to attico-antral disease with
bone involvement surgical treatment is necessary. The chief signs indicating
a need for operation are: (1) A discharge which remains foul-smelling in
spite of antibiotic and antiseptic treatment. (2) Granulations which recur
rapidly after removal. (3) Mastoid abscess or a sinus into the external meatus
or opening on to the surface. (4) Facial paralysis (Bell's palsy may develop
concurrently with middle ear suppuration). (5) Cholesteatoma. (6) Meatal
stenosis.

The objectives of surgery are the removal of all diseased tissue, mucosal
and bony, from the middle ear cleft after which tympanoplastic procedures
are employed in reconstruction of the sound conductive mechanism.

The operations performed to obtain these objectives are divided into two
types: (a) Open techniques—the radical or modified radical mastoidectomy
which provide good access for removal of all diseased parts but leave a

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